Case-Based Questions for Teaching Emergency Medicine Pharmacotherapy

Audience This pharmacotherapy curriculum is designed for emergency medicine residents of all postgraduate years and could also be given to rotating medical students during clerkships. Length of Curriculum Curriculum is to run monthly for an 18-month general curriculum cycle Introduction Pharmacotherapy is a critical part of day-to-day practice of Emergency Medicine (EM). The purpose of this innovation is to give this subject specific dedicated instruction time. We introduced a dedicated pharmacotherapy curriculum as part of our conference time through a series of case-based question sets that mirrored our educational blocks. Educational Goals Our goals were to teach residents clinical applications of EM pharmacotherapy including drug selection and consideration of alternatives, interactions, and adverse effects, as well as to prepare them for pharmacotherapy questions on board examinations. Educational Methods The educational strategies used in this curriculum include: case-based vignettes, multiple choice assessments, and guided review explanation and discussion. Questions and explanations are written by resident physicians using a variety of textbooks and online resources and are then reviewed, edited, and expanded upon by attending physicians and an EM pharmacist. Research Methods This curriculum was implemented in the University of Pittsburgh Emergency Medicine residency program. Curriculum is ongoing and initial data covers a 4-month pilot period. Survey questionnaires were given before and after, using the 7-point Likert scale (1 strongly agree to 7 strongly disagree) for self-assessed knowledge and satisfaction with the curriculum. Primary measure was resident agreement with the statement, “I am confident in overall knowledge of EM pharmacotherapy.” We also surveyed readiness for independent practice, knowledge appropriate for training level, board exam preparedness, and satisfaction with curriculum. Results On the whole residents did feel their pharmacology knowledge improved. Our primary marker was response to a survey question, “I am confident in my overall knowledge of EM pharmacotherapy.” In our sample of 30 residents, this question received a pretest score of 3.7 on a 7-point Likert scale (1 strongly agree, 7 strongly disagree). On post intervention surveys this score had improved to 2.6 (p = .00008). In general, residents appreciated this change in curriculum structure. Resident assessment of their improvement during the curriculum was 2.1, aligning with “agree.” Satisfaction also improved from a 3.8 on initial survey to a 3.1, with statistical significance (p =.023). Discussion We had success in our primary outcome of self-assessed resident learning as above. Satisfaction also improved. Residents assessed self-improvement in knowledge relative to year of training, clinical practice ability, and independent practice ability by statistically significant amounts. In addition, the assessments provided the residency clinical competency committee with objective knowledge of pharmacotherapy-based topics. We feel this easy to implement and effective curriculum would be generalizable across programs looking to add options for teaching EM pharmacotherapy, or to other programs looking to add a formal instruction and evaluation component to traditionally informal curriculum. Topics Emergency Medicine, education, pharmacotherapy, case based, questions, milestones.

The purpose of this innovation was to address a deficiency in the current didactic curriculum design by creating a dedicated curriculum and assessment of the pharmacotherapy milestone. In our institution, the pharmacotherapy content was taught through occasional lecture points or as needed on shift, but without any formal curriculum. Unlike other milestones that have dedicated rotations, such as ultrasound or prehospital care, or more rigorously codified expectations and evaluations, i.e., procedures (such as vascular access) and medical knowledge (in-service scores), pharmacotherapy was more difficult to assess and standardize teaching. Our Clinical Competence Committee repeatedly had little subjective or objective evidence regarding this milestone leading to anecdote-based assessment or general gestalt among the committee. Adding an entire pharmacy rotation is impractical, but a more focused and longitudinal educational initiative could be undertaken. Additionally, this curriculum allows for more direct assessment of this milestone that was not previously directly addressed at this institution. 7 Previously published curricula include those for instructing an entire organ system block or one focused area of instruction. We did not find a published curriculum of one milestone instructed in a longitudinal fashion across organ system/topic blocks. We sought to provide a formal and specifically directed curriculum in parallel with our longitudinal 18-month curriculum. This means of instruction draws inspiration from national question banks used in preparation for board examinations such as USMLE and ABEM board certification. It has been shown that completion of more unique USMLE prep questions was correlated with improved score. 8 We sought to apply this approach to the more focused subject matter of EM pharmacotherapy. We sought to combine clinical teaching pearls, board content, and topics from the ABEM model of clinical practice using case-based situations. The framework included approximately 10 questions during each organ system block. The curriculum had the potential to impact all residents by providing a formal source of pharmacotherapy instruction. The confidence of our residents in pharmacotherapy topics was assessed prior to the initiation of the curriculum and scores suggested an educational need for an additional focus on pharmacotherapy.

Goals of the curriculum:
The goal of this curriculum is to educate EM residents of all PGY years in the clinical practice of EM pharmacotherapy and prepare them for in-service and board examination. They should be able to correctly determine the indicated pharmacotherapy for a given condition and consider alternatives, contraindications, and adverse effects. The curriculum also serves to give residency clinical competency committee a means for assessing progress along the pharmacotherapy milestone.

Objectives of the curriculum:
The learner should seek to improve knowledge of appropriate pharmacotherapy treatments for common and life-threatening emergency medicine presentations, as well as common and clinically significant contraindications and side effects. Knowledge improvements are to be assessed pre-and postcompletion of the curriculum. The specific objectives modeled after the ABEM milestones: PT2, PT5, PT6, PC5 level 3 and 4, PC 11, PC 13 and are as follows: 1. Select appropriate pharmaceutical for both rare and common emergency medicine presentations 2. Identify relative and absolute contraindications to specific pharmacotherapy 3. Identify alternative therapies for patient allergy considerations 4. Identify side effects and other effects of pharmacotherapy

Educational strategies:
Educational strategies used include clinical vignettes followed by multiple choice questions to elicit knowledge, application, and recall of EM pharmacotherapy. These question sets were followed by a period of review and discussion to further solidify this knowledge because long term retention is improved by a period of feedback following multiple choice testing. 9 Residents were given 10-15 minutes to complete a paper copy of the question set. Immediately following the completion of the question set by residents, the questions were then discussed as a large group. Discussion was led by the resident responsible for writing the questions along with faculty. Approximately 1-2 minutes were spent on each question discussing the reasoning and pertinent pharmacology behind the correct answers as well as the incorrect answers. If a resident was unable to attend educational conference in person, an electronic form of the quiz was sent via e-mail. Once the absent resident returned a completed version of the quiz, they were then sent an answer key with explanations of the correct and incorrect answers. This educational curriculum is focused on the core content of emergency medicine and is foundational knowledge to the specialty. It is relevant and appropriate for learners of all residency years as well as medical students. We implemented this during our regular educational conference as opposed to adding an additional asynchronous requirement. We felt this was useful and well-received as a means to provide additional education and instruction without placing additional time burdens on busy residents. Other options could include asynchronous completion of the questions with in-person review. We collected survey data pre-and post-pilot period implementation of this curriculum after 4 months. We provided the curriculum to residents of all three PGY years for a total of 48 residents at a time. Given a transition of academic years during the study period, we had a total of 54 residents and some additional medical students who participated in this curriculum. We collected completed efficacy data on 30 of the 32 residents completing the pre-intervention and post-intervention surveys. We chose this population because they were the two classes of residents who would be in training throughout the entire study period, thereby allowing us to perform matched analysis of the pre-and post-intervention scores. We measured pre-and post-test selfassessed knowledge and satisfaction with the curriculum after the first 4 months of implementation using a survey with several questions using a 7-point Likert scale from 1 (strongly agree) to 7 (strongly disagree).

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For our statistical analysis, we used a Wilcoxon signed rank test, given our sample of paired data from the 30 residents that completed both surveys. Our primary marker was the response to, "I am confident in my overall knowledge of EM pharmacotherapy." This received a pre-intervention score of 3.7 and a post score of 2.6 (p = 0.00008), achieving statistical significance. For the survey item, "I am confident in my ability to apply my knowledge of EM pharmacotherapy to clinical practice," we saw an improvement from 3.2 to 2.3 (p = 0.0004). Resident assessment of knowledge being appropriate for level of training showed an improvement from a mean of 3.0 to a mean of 2.3 with a (p = .010). Our largest degree of improvement was in self-assessed readiness for independent practice, improving from 4.3 to 3.0 (p = 0.0003). Satisfaction scores improved from 3.8 to 3.2 (p = 0.022), indicating a statistically significant, positively received change from original curriculum style to the intervention.
We hypothesized the potential for improvement in preparedness for the in-service exam. For the residents' selfassessed level of preparation for the in-service exam, we saw a trend towards a better self-assessed preparation from 3.2 to 2.7, but this did not reach statistical significance (p = 0.057). Additional data would need to be gathered to determine any degree of impact on actual results of the exam, and pharmacology related questions are not specifically identified on score reports.
Self-assessed knowledge improvement received a score of 2.2 (SD 0.92). This was only assessed on the post intervention survey, and was a response to item, "My knowledge of EM pharmacotherapy has improved by completing these cases," corresponding to "agree" on the Likert scale. Participants' assessment of the efficacy of the intervention, "I believe these cases were an effective means of learning EM pharmacotherapy," scored a 2.3 (SD 1.1), also corresponding closely to an assessment of agreement.
We also included an area in the feedback form for open response for ways to improve the content and implementation of the curriculum. As a result of this feedback, we are working to expand the explanations of both correct and incorrect answer choices as well as provide additional feedback and discussion time. In the feedback section, one resident raised an interesting point about a possible confounding effect: "If my post-survey does not show improvement in our education following your intervention, it is because your intervention has just made me more aware of how much I don't know." The very act of education can raise awareness of knowledge gaps that were not reflected in the pretest surveys.
It is possible our finding of such improvement in independent practice readiness could be confounded by the time that had passed during the instruction period, moving all residents closer to the time they would be expected to possess independent practice capabilities. However, we would expect at least a substantial portion of this change arises from our targeted intervention, and we limited the time from the before and after survey to limit changes due external knowledge and forces.

Evaluation and feedback:
In addition to our expanded explanations detailed above, we are working on creating an expanded question bank to allow for ongoing application because our program education cycle repeats every 1.5 years. As the question bank is developed, there will be an increasingly large bank from which to pull questions related to a specific subject matter. For residents unable to attend educational conferences due to clinical or other obligations, a copy of the quiz was sent via email and an answer key with explanations of the correct and incorrect answers was sent once they returned the completed quiz. Constructive feedback mostly centered on increasing extent and quality of explanations for incorrect answers, which have been added to the attached materials. We did find a previous study demonstrating a correlation between resident performance on regular multiple-choice quizzes and the inservice examination, and it may be possible in further study to correlate our quiz scores with in-service examinations, or possibly as a means to identify a lower-performing cohort of residents for early intervention or extra instruction. 10

6.
A 47-year-old man with a history of asthma and atrial fibrillation presents to the emergency department in respiratory distress with wheezing and poor air movement after a treatment with albuterol and ipratropium-bromide administered by medics. You start a continuous albuterol treatment and note the patient to be tachycardic and irregular at a rate of 150, consistent with atrial fibrillation with rapid ventricular response. In addition to fluid resuscitation, what treatment would you initiate for rate control?
a. Metoprolol b. Verapamil c. Adenosine d. Atropine

Beta blockers are not the preferred choice for treatment of a-fib in patients with asthma/COPD because the beta-blockade can potentiate worsening bronchoconstriction. Adenosine is not indicated in the treatment of atrial fibrillation.
Atropine would likely worsen the patient's condition.

7.
A 3-day-old infant presents to your emergency department by EMS for poor feeding and lethargy. On examination you find a cyanotic infant, with poor tone, tachypnea and central cyanosis. IV access is obtained via a scalp IV. Stat portable CXR shows an "egg on a string" with narrow mediastinum and increased pulmonary vascular markings. What treatment should you empirically initiate? a. Large ischemic MCA (middle cerebral artery) stroke 4 months ago with residual weakness b. Breast cancer with metastasis to brain c. Current use of warfarin d. SBP (systolic blood pressure) on 210 on arrival to ED The other choices would be relative contraindications to tPA (tissue plasminogen activator); known brain metastases would be absolute contraindication.

9.
A 79-year-old male presents to the emergency department with dyspnea and altered mental status. On arrival vital signs are HR 111 BP 77/50 RR 23 T 37.1°C O2 sat 95% on NRB. Examination reveals 3+ LE edema, 5 second capillary refill with cold extremities, and diffuse rales. You evaluate with bedside echo and see LV (left ventricle) and RV (right ventricle) dilation with EF (ejection fraction) estimated 10-15%. Diagnosing acute decompensated heart failure and cardiogenic shock, you elect to begin inotropic support with milrinone in addition to other therapies. What is the mechanism of action of milrinone? Beta blockade indicated to decrease shear stress in case of dissection. Beta blockers decrease shear stress by decreasing both heart rate and blood pressure. Sodium nitroprusside can be used as an adjunct therapy but should not be used first line because it can cause a reflex tachycardia. Calcium channel blockers could be considered in patients with severe asthma/COPD to avoid beta-blockade but a nondihydropyridine such as diltiazem would be preferred because the action at the AV (atrioventricular) node helps prevent reflex tachycardia.

12.
A 24-year-old male presents to your emergency department short of breath after just returning from Santiago, Chile. He has rales throughout pulmonary fields and decreased ejection fraction on bedside echo. You suspect Trypanosoma cruzi infection and initiate empiric treatment with? 13. A 19-year-old male presents to the emergency department for chest pain that is worse when lying down at night. You note a small pericardial effusion on bedside echo. Which of the following treatment regimens is associated with fastest resolution of symptoms and lowest rate of recurrence?

a. Prednisone and colchicine b. Indomethacin and prednisone c. Colchicine and aspirin d. Aspirin and indomethacin
The question stem describes pericarditis. Colchicine and aspirin are associated with the fast resolution. Prednisone can increase rate of recurrence. Choice D is aspirin and NSAID which would have lower efficacy compared to colchicine and aspirin as well as having increased risk of negative side effects such as GI bleed.
14. An 89-year-old woman presents to the emergency department for heart palpitations and dizziness. Her vital signs are HR 220 BP 100/60 RR 18 T 37.2°C O2 sat 96%. She is alert and oriented. The patient is placed on the cardiac monitor which shows a rhythm concerning for ventricular tachycardia. Treatment is initiated with amiodarone. Which of the following is not an acute adverse effect of amiodarone? The stem is describing concern for infectious diarrhea.

2.
A 23-year-old male with no personal medical history presents with 1 week of joint pain. He states that he began having aching pain in his right wrist and ankle early this week, and now his left knee is particularly painful and swollen. He also endorses generalized malaise and some subjective fever at home. He has been sexually active with several partners in the past 2 months. Temp of 38°C on presentation and vitals otherwise within normal limits. Physical exam reveals tender, swollen left knee, and the dorsal aspect of bilateral wrists is tender to palpation. You notice a painless macule on the palm of the left hand. Arthrocentesis performed on knee and synovial fluid analysis shows opaque